What are the ESMO guidelines on management of advanced or metastatic renal cell carcinoma (RCC)?

Updated: Jun 08, 2020
  • Author: Kush Sachdeva, MD; Chief Editor: E Jason Abel, MD  more...
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Answer

European Society for Medical Oncology (ESMO) recommendations for management of advanced or metatstatic RCC are as follows [76] :

  • Cytoreductive nephrectomy is recommended in patients with good performance status (PS), except in intermediate/poor-risk patients with asymptomatic primary tumors when medical treatment is required.
  • Radiation therapy (RT) can be used to treat unresectable local or recurrent disease and in patients unsuitable for surgery due to poor PS or unsuitable clinical condition. RT is an alternative if radioablation is not appropriate
  • Image-guided RT techniques such as volumetric-modulated arc therapy (VMAT) or stereotactic body radiotherapy (SBRT) are needed to enable a high dose to be delivered.
  • RT is an effective treatment for palliation of local and symptomatic metastatic RCC or to prevent the progression of metastatic disease in critical sites such as bones or brain.
  • For RCC with brain metastases, corticosteroids can provide temporary relief of cerebral symptoms. Whole-brain radiotherapy (WBRT) of 20-30 Gy in 4-10 fractions is recommended for effective symptom control. For good-prognosis metastatic RCC patients with a single unresectable brain metastasis, sterotactic radiosurgery (SRS) with or without WBRT should be considered.
  • For first-line systemic treatment, VEGF-targeted agents and tyrosine kinase inhibitors (TKIs) are recommended options for good- and intermediate-risk patients. Tivozanib is approved by the European Medicines Agency (EMA) for good-risk patients. The combination of nivolumab and ipilimumab is recommended for intermediate0- and poor-risk patients, but not for the good-risk group. Cabozantinib is EMA approved for intermediate- and poor-risk groups.
  • For second-line treatment, following TKIs, nivolumab, cabozantinib, or tivozanib are recommended.
  • The combination of lenvatinib and everolimus following TKIs is FDA- and EMA-approved and is recommended after the nivolumab/ipilimumab combination.
  • If none of those drugs is available, either everolimus or axitinib can be used.
  • In patients already treated with two TKIs, either nivolumab or cabozantinib is recommended.

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